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WELL DRILLING BOARD . STATE OF CONNECTICUT PEERMIITT NUMBER
WDB-4; 1 T=69 1 V A
�--""> WELL DRILLING PERMIT 4
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL(Town) (Street) (Lot Number) DATE
i
OWNER OF WELL
❑ INDIVIDUAL
IDUAL � BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
?�tv CIII14 14.
PROPOSED BUST ESS TEST Est.No.of
USE OF r.
ILIC
ESTIC ESTABLISHMENT ❑ FARM ❑ WELL People being
served.
WELLi. AIR OTHER
® SUPPLY - ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to otJeo ;two roads,showing distance from intersection and front of lot
Location of lot to at least two roads'"VIIIOW' gVett Jacation°`tm--to�"d tol house fif`presemtJ
Ptle
Indicate North ti
IPA.
w�r�
n
Approximate number of feet from well to
nearest source of possible contamination: d
The undersigned is aware that upon completion of the well,a"Well Completion Report'' containing construction details and information required under Section 6 of,,
Public Act 659 must be sent to the owner,the Board and the Water Resources Commission on the form provided by the Board.This permit is not valid until all informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
"CANT'S DDRESS REGISTRATION NO.
BY(Tow eatth icer or Agent) DATE
❑APPROVED ❑ REJECTED ,
i. REMARKS _--_
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DIRECTOR OF HEALTH